118 Chapter 5 and reimbursement both at a national level. Second, for the cost calculation, we used time-driven activity-based costing, which helps care providers understand the major cost drivers and find points of action for lowering costs.3,36 Third, we performed a probabilistic sensitivity analysis to estimate the uncertainty surrounding our budget impact estimates.37 However, some limitations need to be addressed. We used different data sources to estimate the actual costs of MLC-aCTG and OLC-aCTG, including a specifically conducted survey, prospective cohort data and national registry data. Although we tried to be as precise as possible in estimating costs, actual costs in clinical practice may differ from our estimations. Unfortunately, we do not have data for training and CTG equipment costs in OLC, and we assumed in our study equal costs for these components in OLC-aCTG and MLC-aCTG. However, these costs are expected to be lower in OLC, given that the volume of CTGs is higher. This may lead to a lower rate of actual costs of OLC-aCTG. In our analyses, we only focused on the actual costs of performing the aCTG in MLC or OLC without considering a possible impact on the percentage of women that remain in MLC in either of the two care models. Since we expect that more women will stay in MLC when the aCTG is conducted in MLC than in OLC, where the chance of medical interventions is lower,38 we expect total childbirth costs to be lower for MLC-aCTG. Future research should address this, for example, in a large prospective cohort study. We chose to focus on the direct material costs, which comprise the majority of expenses incurred in clinical practice. We did not consider the costs of sterilisation, housekeeping, finance, and information and communication technology. Although this might have impacted the costs, we do not expect this would alter our conclusion as this difference will be minimal compared with the costs we have included. Finally, in this study, we performed a budget impact analysis considering the financial consequences of implementing MLC-aCTG. It was not possible to perform a cost-effectiveness analysis that included outcomes such as safety and women’s satisfaction with the data we had available. However, we have assessed quality of care and women’s satisfaction in separate publications and have shown that there are no differences in the quality of aCTG assessment between primary care midwives, hospital-based midwives, residents and obstetricians.10 In addition, our previous work has shown reassuring maternal and perinatal outcomes after MLC-aCTG and high levels of women’s satisfaction with this care.11,12 Considering the impact of costs, quality and satisfaction together is crucial when implementing a value-based healthcare innovation such as MLC-aCTG. CONCLUSION Our findings suggest that shifting aCTG from secondary OLC to primary MLC may increase the associated actual costs for healthcare professionals. At the same time,
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